Suzanne Gordon

Suzanne Gordon is a journalist and co-editor of a Cornell University Press series on health-care work and policy issues. Her latest book is The Battle for Veterans' Healthcare: Dispatches from the Frontlines of Policy Making and Patient Care. She has won a Special Recognition Award from Disabled American Veterans for her writing on veterans' health issues, much of which has appeared in The American Prospect. Her website is www.suzannegordon.com.

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In a now familiar pattern, leading veterans organizations are up in arms again over the latest revelations about White House plans for the Veterans Health Administration (VHA)—plans that were concocted behind closed doors.

Last week, the Associated Press reported that Secretary of Veterans Affairs David Shulkin and other Trump officials have been quietly discussing ways to shift veterans, now eligible for VHA care, into Tricare, the private insurance program for active duty military personnel and their families. The administration’s Tricare discussions have been conducted without input from members of Congress or veterans groups.

In recent months, Amvets, Disabled American Veterans, the American Legion, and other veteran service organizations have become increasingly worried about the Trump administration’s moves to out-source more VHA services through expanding a program called “Choice,” which reimburses non-VHA doctors and hospitals that treat veterans.

Veterans’ advocacy groups have reacted with shock and anger about the prospect of a VHA merger with Tricare, which pays for private-sector health-care services. Such a move could ultimately lead to the dismantling of the VHA, which provides integrated, direct care for nine million patients at 1,700 facilities nationwide.

As Louis Celli, a top staffer for the American Legion, told the Associate Press, a merger would siphon off funds from VHA hospitals and clinics and eventually shift costs directly to veterans, through co-pay and other possible fee increases. (Tricare patients have recently started paying higher co-pays.)

Curt Cashour, a Veterans Affairs Department spokesman, called the concept a possible “game-changer” that would save taxpayers money because it is based on “the type of businesslike, common-sense approach that rarely exists in Washington.”

Recently, congressional Republicans have tried to convince veterans that the troubled Choice program should be renewed with even fewer restrictions on veterans who want to use private-sector providers—even though the program has been rocked by $2 billion in cost over-runs. (The VA Inspector General released a report in September that also revealed that the third-party contractors responsible for the Choice program had overbilled the federal government by almost $90 billion in 2017.)

The author of one such proposal is Representative Phil Roe, the Tennessee Republican who chairs the House Committee on Veterans Affairs. He has insisted that his bill, the VA Care in the Community Act, would actually strengthen veterans’ health services. Some Democrats on the House Veterans Affairs Committee, like Tim Walz of Minnesota, even co-sponsored Roe’s bill, despite the VHA privatization threats. But others, including California Democrat Mark Takano, a staunch supporter of the VHA and ally of veterans group, sought major changes in the legislation that would ensure the VHA maintains a critical role in providing direct care to veterans and coordinating any care veterans receive in the private sector with services provided by the VHA.

But with the revelations about secret meetings, Walz now believes that the real White House goal is “to force unprecedented numbers of veterans into the private sector for their care.” In response to the AP story, Walz demanded that the administration release “unredacted copies of any and all documents, records, memoranda, [and] correspondence” related to the private insurance scheme.

This latest development in the long-running Koch brothers–backed campaign to turn veterans into private-sector health-care customers should not come as a surprise. As The American Prospect has previously reported, when the Choice program was initially created in 2014 to deal with VHA appointment delays, Congress and the Obama administration also formed a VA Commission on Care to make recommendations to improve the health-care system. But health-care industry executives and allies of the Koch brothers who favored VHA privatization influenced the commission’s findings. Darin Selnick, a top official of the Koch brothers–funded Concerned Veterans for America (CVA), served on the commission and later became a senior adviser to Shulkin.

The Prospect also reported that a conservative faction on the commission known as the “Strawman group” short-circuited public deliberations about the future of the VHA by meeting in secret. Their “minority report” called for replacing the VHA with an insurance scheme like Tricare. One Strawman group member, Obama appointee Joyce Johnson, is a top Coast Guard official who helped to move the Coast Guard into Tricare.

Secretary Shulkin’s secretive approach raises new questions about how he intends to run the agency. Last winter, the VHA’s defenders breathed a collective sigh of relief when Trump decided to keep Shulkin (who served as the VHA undersecretary for health under former President Obama) in his cabinet. (The other leading contenders for the job, Pete Hegseth, former CEO of the CVA, and Florida Republican Jeff Miller, the former chairman of the House Committee on Veterans Affairs, had both publicly supported VHA privatization.) His credibility among veterans may take a big hit if he continues to speak out against privatization while working behind the scenes to steer the VHA in that very direction.

In September, The American Prospectreported that budget cuts at the Veterans Health Administration would have eliminated the system’s ten Patient Safety Centers of Inquiry. After protests from leading patient safety experts and members of Congress, the centers were saved. But late last month, brand new threats emerged that could jeopardize the VHA’s ability to serve mentally ill, homeless, and female veterans; prevent veteran suicide; and increase access to needed services.

An internal VHA memo signed by Poonam Alaigh, then acting under secretary for veterans affairs for health, informed VHA deputy under secretaries, chiefs of staff, and network directors that they are free to shift almost $1 billion in funds allocated to specific VHA programs either to their general operating budgets or to finance Veterans Affairs Secretary David Shulkin’s five new VHA priorities. Shulkin’s priorities include outsourcing more care from the VHA to private-sector hospitals and doctors as well as creating more suicide prevention programs.

The memo obtained by the Prospect has caused a stir at the agency’s downtown Washington headquarters and the funding transfers were temporarily put on hold. But after agency officials conduct a detailed review, some cuts may still go forward.

Homeless veterans advocates are deeply disturbed that the list of targeted programs includes more than $265 million in spending for the Housing and Urban Development’s VA Supportive Housing (HUD/VASH) program’s social workers who work with homeless veterans. The HUD/VASH program “is the chief strategy to reduce veteran homelessness,” says Randy Shaw, who directs the Tenderloin Housing Clinic in San Francisco.

“The HUD/VASH program has allowed VHA case managers to work in partnership with local and municipal homeless programs to reach chronically homeless vets,” says Michael Blecker, the executive director of Swords to Plowshares, a San Francisco veteran service organization. “Allowing the program to literally be zeroed-out sends the worst message to all the VHA partners who have helped make the program so successful.” Anything that jeopardizes HUD/VASH social workers or vouchers, Shaw agrees, would be “disastrous.”

Other programs on the chopping block include $30 million in additional mental health initiatives and $21 million for coordinators who help Iraq and Afghanistan veterans transition to civilian life. Potential downsizing or elimination of the delivery of mental health and rehabilitation services, suicide research, and myriad of other programs jeopardize the secretary’s stated commitment to preventing veteran suicide among veterans.

The new shifts in funding also target funding for spinal cord injury programs, rehabilitation programs, and amputation care for those who have suffered disabling injuries on and off the battlefield. The plan also includes trimming almost $26 million allocated to Mental Illness Research Education and Clinic Centers. These Centers do pioneering research on the causes and treatments of mental disorders and translate this new knowledge into routine clinical practice with veterans.

Almost $23 million in funding for occupational health and safety programs could be eliminated and some training programs for VHA staff have already been canceled. These programs teach staff how to safely lift and handle vulnerable veterans in VHA hospitals and nursing homes as well as how to deal with “disruptive” veterans who are a danger to themselves as well as those who care for them. Programs to prevent workplace violence have also been targeted. After much prodding from women veterans and groups like the Iraq and Afghanistan Veterans of America (IAVA) the VHA initiated many programs to better serve women veterans. Potential cuts, however, include $6 million devoted to women’s health.

Although the secretary insists he wants to increase veterans’ access to needed services and recruit staff to fill the VHA’s 34,000 vacancies, potential shifts in funding away from primary and geriatric care, and telehealth, will also affect access. If the secretary is really committed to expanding access to VHA services, why is the VHA’s “Educational Debt Reduction” program, used to provide incentives to recruitment in rural areas, on the list?

The memo tries to soften the blow of these proposed cuts by suggesting that giving medical and regional directors the flexibility to use funds allocated for specific programs as they see fit won’t “completely eliminate” specific programs. This optimistic assessment ignores current fiscal reality at the VHA. The cost of outsourcing VHA care to the private sector, has, according to another internal VA memo been a “major driver, in budget shortfalls for VHA facilities across the country.”

Medical centers and regional offices have been strapped for cash to fund operating expenses. Without additional infusions of funding, directors will be very tempted to use these newly available funds to pay for day-to-day operations.

VHA officials would not have to resort to the types of choices that could inflict more pain on the men and women who have fought in the country’s wars, if President Trump backed adequate funding levels for the agency. Ken Watterson, president Dallas Veterans Resource Center and founder of Homeless Veteran Services of Dallas, says Washington needs start listening: “It’s time for veteran service organizations— and veterans—to make it clear that balancing the budget on the backs of veterans is not the choice they want.”

The Department of Veterans Affairs (VA) is considering budget cuts that could jeopardize patient safety in the nation’s largest health-care system. On the chopping block are ten VA Patient Safety Centers of Inquiry (PSCIs), facilities that have long pioneered innovations to reduce injury, addiction, and suicide that have impacted patients far beyond the VA system. While the administration claims such goals are high priorities, these facilities could be shut down by September 30.

The potential closure of these patient safety centers is part of a broader attempt to cut costs within the nation’s largest health-care system. Surging demand for services at the Veterans Health Administration (VHA) and the high cost of paying for expensive, outsourced care in the private sector through the Veterans Choice and other Community Medical Care programs has caused a significant budget shortfall in VHA facilities across the country.

Despite this shortfall, Trump refuses to go to Congress for more money than currently budgeted for the VHA. Now VA leadership is focused on shifting pots of money from what are known as specific-purpose budgets (which includes the PSCI’s small $2.5 million budget) to general-purpose budgets. In the case of these patient safety centers, this robbing-Peter-to-pay-Paul approach will hurt veterans rather than help them. Since the VHA’s leadership in patient safety extends way beyond VHA facilities and the patients served by them, this move may also impact millions of non-veterans who also benefit from VHA research and safety practices.

In a country where more than 250,000 patients die each year due to preventable medical errors (which are America’s third leading cause of death) and more than 1.5 million are seriously injured, the VHA has become a beacon of progress in patient safety. Since the mid-1990s, the VHA has been “a bright star in the constellation of safety practice, with system-wide implementation of safe practices, training programs,” according to physicians and patient safety leaders Donald Berwick and Lucian Leape.

As patient safety leaders have long documented, turning theory into safe practice involves way more than passing around scientific journal articles, or writing patient safety policies and protocols. Motivating front-line caregivers to do everything from cleaning their hands to prescribing opioids safely involves putting what is known as evidence-based medicine and best practices into actual daily use.

Today, at the veterans hospital in White River Junction, Vermont, the Patient Safety Center of Inquiry has developed tools aimed at sharing critical information about the early warning signs of suicidal behavior among veterans. Their counterparts in Durham, North Carolina, are trying to target extremely painful surgical procedures, like the knee replacement operations so common in the aging veteran, and help surgeons manage patients’ pain without overreliance on addictive opioids. One goal of this program is to keep former members of the armed forces from adding to the grim national death toll of the opioid epidemic.

At the PSCI in Tampa, Florida, VHA researchers are designing new tools to reduce the risk that older veterans will fall and break a hip, either in their own homes or an in-patient setting. Meanwhile, the PSCI in Boston is developing ways to reduce exposure to potentially fatal hospital-acquired infections like methicillin-resistant Staphylococcus aureus.

VHA safety leaders say they are stunned by the proposed closure of their PSCIs. “VA leadership is looking for easy answers and quick solutions and are not taking the time to fully understand the consequences of their actions,” a long-time VA patient safety researcher told The AmericanProspect. “They are so focused on issues of access that they don’t ask questions about what kind of system patients have access to.”

Doctors like Lucian Leape share these fears. In a letter to VA leadership, Leape protested the potential closure of PSCIs, praising the centers’ “important contributions,” and said he echoed the “concern of other patient safety leaders nationwide that losing the PSCI program would terminate one of the most efficient and productive translational safety programs in the VA.” Hopefully, the Trump administration will not decide to pinch pennies at the expense of veterans’ lives.

Secretary of the Department of Veterans’ Affairs, David Shulkin, has pledged not to privatize the Veterans Health Administration (VHA). He understands, he says, that the VHA’s ability to provide care that, as studies document, is superior to those in the private sector is because veterans are treated in an integrated system that meets all their health needs. In testimony to the House Committee on Appropriations Veterans Oversight Hearing on May 3, Shulkin argued that unlike the private sector, the VHA “defines health far more broadly as physical, psychological, social, and economic.” Such a “unique national resource … often cannot be found in the private sector.”

In spite of this some of Secretary Shulkin’s recent decisions are very troubling. In March, Shulkin announced that the VHA would begin providing emergency mental health services to veterans previously ineligible for them. While that coverage is long overdue, the VA’s budget will likely push some already enrolled patients out of the VHA system and onto private providers. At the same time, Shulkin has proposed outsourcing optometry and audiology care to the private sector. In both cases, the changes threaten to jeopardize the kind of integrated services the VHA provides.

For years, the VHA has not been able to provide care to an estimated 500,000 veterans who have what are known as “other than honorable” (OTH) discharges (as documented by the San Francisco-based veterans service organization Swords to Plowshares). This is because a veteran’s eligibility for VA benefits is determined by the kind of discharge they receive when they leave the military. Only those with honorable, general, or medical discharges qualify. Those with “other than honorable discharges” or “dirty or bad papers” are disqualified because they committed acts that, while not worthy of a court marshal, led to their discharge. In reality, many of these vets went AWOL, got into fights, abused drugs or alcohol, or had discipline problems because they had PTSD, suffered from military sexual trauma, or other conditions arising from their military service.

Shulkin has announced that he wants to provide these veterans with emergency mental health services if they are in crisis, but his position on funding the coverage is worrisome. During his Appropriations Committee appearance, Shulkin was asked how he would pay for caring for hundreds of thousands of veterans who may not have had health-care services for years, even decades. “Maybe this doesn’t fit into the budget,” he replied. “But frankly I don’t care … I don’t want more money for this. We’re going to figure out a way to help these people and then connect them to community resources and get them help because this is the right thing to do.”

Serving these veterans is definitely the right thing to do. But creating what could be an unfunded mandate may be the wrong way to do it. As Shulkin admitted during his testimony, the VHA is already short 1,500 mental health professionals needed to serve its currently enrolled patients. It will need more staff, and more inpatient psychiatric beds, and outpatient services to care for hundreds of thousands more.

“By definition, the veterans with OTH discharges need intensive mental health treatment because they will enter our system only when they are in crisis,” one VHA psychologist, who asked to remain anonymous, told the Prospect. “Many will have to be admitted to inpatient units and not every facility has enough beds. They will also need intensive treatment. We want to help them. But we need the staff and funds to do it well.”

Veterans with OTH discharges are also, by definition, ineligible to be referred to Choice care in the private sector, the psychologist explained. If the VHA does not have sufficient mental health staff to care for them, currently eligible veterans with mental health problems will face longer wait times or be pushed into Choice. They will thus be referred to private sector providers, who as numerous studies document, may not be trained to treat their complex, military related conditions.

More recently, Shulkin has proposed yet another way he may seek to privatize VHA services. Shulkin has told VA health-care directors from around the country that he wants to stop providing audiology and optometry services. “There are LensCrafters on every corner,” the secretary reportedly commented. Not only would this impact the optometry and audiology training the VHA provides to future clinicians, it would curtail two of the most popular and cost effective services the VHA delivers.

Hearing problems from toxic noise exposure are, in fact, a primary reason veterans seek VHA care. VHA optometrists do more than prescribe eyeglasses. Among other things, they evaluate whether patients with impaired vision are eligible for the impressive services offered through the VHA’s national system of 13 Blind Rehabilitation Centers.

And like all VHA employees, VHA audiologists and optometrists are trained to recognize if patients are at high risk for suicide. Would a technician at LensCrafters recognize that a veteran is seriously depressed and contemplating suicide if the patient (now customer) makes a stray comment indicating that he may not be around to collect his glasses?

Outsourcing public sector services and starving a public institution of necessary funding is one of the facilitators of privatization. The challenge facing Shulkin is how to respond to real needs and problems without setting in motion what Garry Augustine, executive director of the Disabled American Veterans, has called the “withering on the vine” of the VHA.

Lawmakers on Capitol Hill mulling legislation to extend a program that lets veterans seek health care in the private sector have revived their longstanding complaints about long wait times for care at the Veterans Health Administration facilities. Veterans Affairs Secretary David Shulkin and Dr. Baligh Yehia, the agency’s assistant under secretary, appeared before the House Committee on Veterans Affairs to testify on HR 369, a bill that would allow the Veterans Access, Choice, and Accountability Act to continue past its sunset date of August 2017.

In 2014, after revelations of wait-time problems at some Veterans Health Administration (VHA) facilities, Congress created the three-year Choice program allowing eligible veterans to seek care in the private sector if they live 40 miles from a VHA facility or have to wait for more than 30 days for an appointment. The bill would let the VHA spend what remains of the initial $10 billion (about $1 billion) allocated to Choice on care in the private sector.

At the hearing earlier this month, House Committee on Veterans Affairs Chairman David “Phil” Roe, a Republican from Tennessee, complained of VHA wait times as long as 81 days. His comments and those made by other committee members suggest that congressional Republicans are determined to ignore any evidence that outsourcing care to private sector providers won’t do much to improve access to or coordination of care for veterans. They seemed unaware, for example, that wait times for private-sector health care are also a significant problem.

A 2014 study of wait times in American hospitals by health-care consulting firm Merritt Hawkins found long wait times and large disparities depending on location. In their just released 2017 study of wait times, the firm found that wait times in 15 metropolitan areas had increased by 30 percent since 2014. The average wait time for a new physician appointment was 24 days. In Boston, the average wait time to see a family physician was 109 days while in Albany patients had to wait 122 days. Some practices were entirely closed to new patients. In Boston patients who had to wait to see a cardiologist for 133 days in 2014 were now waiting as much as 365. In Houston the longest wait for a heart doctor jumped from 26 to 43 days. In Denver the longest wait to see a dermatologist went from 180 to 365 days while the shortest delays increased from one to seven.

A 2013 Commonwealth Fund report found that, of those adults surveyed, 26 percent reported six or more days for a primary care appointment when they were actually “sick or needing care.” As the report stated “Among the 11 nations studied in this report; Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in 2010, 2007, 2006, and 2004.”

The American Prospect recently reported on an independent assessment of VHA performance and access which concluded that, “Enrollees living more than 40 miles from VA facilities are much less likely to have geographic access to specialized services in non-VA hospitals … they are much less likely to have access to academic and teaching hospitals, the sites in which more complex care is offered.”

VHA wait times mirror those in the private sector for the same reason, a nationwide shortage of primary care providers and mental health professionals. Another contributing factor is that a government agency like the VHA is unable to offer market-rate salaries to healthcare professionals. In high-cost urban areas, health care professionals who want to work at the VHA are being offered thousands, sometimes tens of thousands, more in the private sector. Not surprisingly, they follow the money. During the committee’s three-hour hearing, the issue of how low pay affected the quality of care never came up.

Committee members also considered another Choice Program problem, the coordination of care between VHA and private sector providers. Committee members offered a number of short-sighted observations, including defining care coordination exclusively in terms of giving private sector providers access to the VHA’s electronic medical records.

Coordinating care for VHA patients who are, on average, sicker, older, poorer, and have more chronic mental health conditions than their counterparts in the private sector, requires far more than access to data. The VHA has pioneered a model of care coordination: Clinicians who work in the VHA system and often in the same work on multidisciplinary teams that have been trained to engage in face-to-face communication (sometimes via Telehealth) about the complex needs of their patients.

As many studies have consistently documented, this is one of the main reasons that the VHA often delivers care that is superior to that treatment delivered by private sector providers. It is also why, as Dr. Shulkin testified, of the 1.2 million veterans who have had appointments through the Choice program in the private sector, only 5,000 of them chose to receive care only from private sector providers.

Shulkin has promised to unveil a new version of the program, what he likes to call Choice 2.0, sometime this fall. The future of the VHA will depend on how this program is configured and if members of Congress are willing to consider whether private sector providers can actually deliver high quality care. The Choice program has not worked well because it was designed hastily and implemented far too rapidly. If the recent House hearing is any indication, Congress may be poised to repeat history with Choice 2.0.

This story has been updated to include newly released data on wait times.